Provider Demographics
NPI:1902847700
Name:MANROSE, ERIC JONATHON (PT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JONATHON
Last Name:MANROSE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 290
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-0290
Mailing Address - Country:US
Mailing Address - Phone:269-945-9520
Mailing Address - Fax:269-945-3368
Practice Address - Street 1:840 COOK RD
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-9616
Practice Address - Country:US
Practice Address - Phone:269-945-9520
Practice Address - Fax:269-945-3368
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011586225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN82650009Medicare ID - Type Unspecified